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I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton Calif. <br /> nq1 Al Telephone* (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 741- 4/, 5-4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued :ZG—��,y <br /> I It <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct # <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> bounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS1 , CENSUS TRACT f <br /> Owner's Name Phone <br /> r <br /> Address <br /> r City <br /> f <br /> Contractor's Name AaQ r ,XPhonea <br /> TYPE OF WORK (Check): NEW WELL DEEP /-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATIONRPUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESQ-i-PII' PRIVY jk4�. <br /> SEWAGE DISPOSAL FIELD G966F89h/SEEPAGE PIT� OTHER <br /> PROPERTY LINE_- PRIMATE DOMESTIC WELIAO f-PUBLIC DOMESTIC WELL <br /> INTENDED USE - TYPE OF WELL--- < CONSTRUCTION SPECIFICATIONS <br /> r <br /> Industrialr'-- Tool Di--�.,�.__D a., of of <br /> � TCable Well Excavation <br /> Domestic/private Drilled Dia -of Well Casing S <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic-Protection Rotary Type of Grout' <br /> Disposal,. ;_ . �6 Other Other Information <br /> Geophysical s ,y Surface Seal Installed By: � <br /> PUMP INSTALLATION: Contracto=' . �` <br /> Type of Pismp. <br /> „� }' t �► H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-:REPAIR: _ -LT-State Work Done <br /> i <br /> PE&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> + } Describe Material and Procedure <br /> I hereby agree toicomply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting..the. well in.use.. The above <br /> information is true--to-the.-best..of my�knowledge--and-belief:—I-WILL—CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANFINAL INSPECTION. <br /> SIGNED , TITLE <br /> D LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE g <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASEJJ4 FIN INSPECTION <br /> INSPECTION BY DATE r7 INSPECTION BY DATE - 7 <br />. � E H 1426 Rev. -1-74 /1-74 2M <br />